Minimum Survey Vendor Business Requirements[1]

National Implementation of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for the Merit-based Incentive Payment System (MIPS) Survey and the CAHPS for ACOs Survey for the Next Generation ACO Model

Applicant organizations (vendor and subcontractors) must currently possess all required facilities and systems to implement the CAHPS for MIPS Survey and the CAHPS for ACOs Survey administered by Next Generation Model Accountable Care Organizations (NGACOs) (referred to as “survey” in the remainder of this document). Subcontractors will be subject to the same requirements as the applicant vendor. Organizations that are approved to administer the survey must conduct all of their survey business operations within the United States. This requirement applies to all staff and subcontractors.

Note: The CAHPS for MIPS Survey is for groups and virtual groups, and APM Entities, including Shared Savings Program ACOs. Groups, virtual groups, and APM Entities may choose to administer the survey. However, Shared Savings Program ACOs are required to report via the Alternative Payment Model (APM) Performance Pathway (APP) and are therefore required to administer the CAHPS for MIPS Survey.

Purpose: Any interested survey vendor is required to possess the following minimum business requirements to ensure that all participating survey vendors are capable of administering the  survey in a consistent, unbiased, and competent manner. At a minimum, this includes basic quality assurance and control systems and activities to prevent disorganized, biased, or illegal data collection.

[1] In prior performance years, CMS provided separate Minimum Survey Vendor Business Requirements for the CAHPS for MIPS and CAHPS for ACOs surveys. Beginning in Performance Year (PY) 2021, CMS is providing a shared, uniform document for both survey efforts.

Relevant Organizational Survey Experience
Relevant Survey Experience
  • Demonstrated experience (minimum of 3 years) in Mixed-Mode survey administration that includes mail survey administration followed by Computer-Assisted Telephone Interview (CATI) administration with non-respondents
  • Demonstrated experience (minimum of 3 years) with patient experience of care surveys, surveying vulnerable populations, and experience in a health care setting
  • Demonstrated experience (minimum of 3 years) conducting surveys of the Medicare population
  • Demonstrated experience with formatting a flat ASCII (American Standard Code for Information Interchange) file using a standardized data layout and submitting encrypted data to an external data warehouse
  • Demonstrated experience in implementing HIPAA (Health Insurance Portability and Accountability Act) and other data security requirements

Note: All applicant vendors must fulfill the above requirements independent of a subcontractor’s experience

Number of Years in Business
  • Minimum of 4 years
Number of Years Conducting CAHPS Surveys
  • Minimum of 3 years experience conducting CAHPS surveys of individuals; all experience is within the last 5 years
Survey Capability and Capacity
  • Project Manager with 3 years of experience with relevant Mixed-Mode (mail survey administration followed by CATI administration with non-respondents)
  • Information Systems Specialist(s) and Computer Programmer(s)/Developer(s) with 1 year of experience:
    • Receiving large encrypted data files in different formats/software packages electronically from an external organization.
    • Processing survey data needed for survey administration and survey response data.
    • Preparing data files for electronic submission.
    • Submitting data files to an external organization.
  • Call Center and Mail Center Supervisor (subcontractor designee, if applicable) with minimum 1 year of experience in the role
  • Have organizational back-up schedule in place for coverage of key staff
  • Don’t use volunteers to conduct any aspect of the survey administration process
Facilities and Systems (all administration modes)
  • Physical facilities and electronic equipment and software to collect, process and report data securely
  • A secure commercial office/facility in which all survey activities are conducted±
  • Facilities and processes to protect the confidentiality of personally identifiable information and patient response data (e.g., hard copy documents must be stored in a locked file cabinet, room, or building)
  • Systems needed to protect the confidentiality of personally identifiable information and survey data received from patients. (e.g., password protections, firewalls, data encryption software, personnel access limitation procedures, and virus and spyware protection)
  • Computers and other equipment needed for survey implementation
  • Systems and ability to receive electronic sample files containing patient-level data (the sample) needed to administer the survey
  • Electronic survey management system to track fielded surveys
  • All system resources are subject to oversight activities, including site visits to physical locations (such as to vendor’s mail facility to observe production of CAHPS for ACOs survey materials and/or call center where CAHPS for ACOs interviews are being conducted)±
Experience with Multiple Survey Languages
  • Prior experience required in conducting survey administration in both English AND at least 1 of the following languages:
    • Spanish
    • Cantonese
    • Mandarin
    • Korean
    • Russian
    • Vietnamese
    • Portuguese
Mixed-Mode Survey Administration

Must have capability to adhere to the following Mixed-Mode survey administration requirements:

  • Mail
    • Must have capability to:
      • Verify addresses of sampled patients
      • Print professional-quality survey instruments and materials according to formatting guidelines
      • Merge and print sample name and address on personalized mail survey cover letters and print corresponding unique sample identification number and provider name associated with each sampled patient on the mail surveys[2]
      • Receive and process (key entry or scanning) returned mail surveys
      • Track and identify non-respondents for survey follow-up mailing
      • Assign disposition codes to identify the outcome of data collection for each sampled case
  • Telephone
    • Must have the equipment, software and facilities to conduct CATI interviews, and to monitor interviewers
    • Must have capability to:
      • Verify telephone numbers
      • Develop computer programs for electronically administering the survey
      • Schedule call backs to non-respondents at varying times of the day/week
  • Assign final disposition codes to reflect the outcome of data collection for each sampled case
  • Track cases from mail survey through telephone follow-up activities
  • Mail survey administration and telephone interviews must be conducted from the physical place of business, not from a residence or virtual office±

[2] “Provider”, in the context of the survey, can refer to a physician, nurse practitioner, physician assistant, or clinical nurse specialist assigned as the focal provider for each sampled patient at the entity.

Data Processing and File Submission

Must have capability to:

  • Scan or key data from returned mail surveys
  • Develop data files and edit the data according to standard protocols (instructions and file format will be provided)
  • Follow all data reporting and data submission requirements, including verifying that data files are de-identified and contain no duplicate cases
  • Export data from the electronic data collection system into the specified ASCII format. Conduct quality checks to confirm that the data are exported correctly and that the ASCII files are formatted correctly and contain the correct data headers and data records.
  • Encrypt data files for transmission per specifications
  • Submit data electronically in the specified ASCII format to the secure data warehouse
  • Work with CMS’s data warehouse contractor to resolve issues or problems with data submission or data files
Data Security
  • Execute business associate agreement with groups and virtual groups, APM Entities including Shared Savings Program ACOs, and/or NGACOs
  • Receive annual authorization from groups and virtual groups, APM Entities including Shared Savings Program ACOs, and/or NGACOs to collect data on their behalf and submit to CMS
  • Store returned paper surveys in a secure and environmentally safe location (e.g., locked file cabinet, closet, or room)
  • Use firewalls and/or other mechanisms to protect electronic files
  • Employ electronic security via implementation of access levels and passwords
  • Implement daily data back-up procedures that safeguard system data
  • Use required encryption protocols for transmitting data files including, but not limited to, transmission of protected health information (PHI) or personal identifying information (PII). Transmission of these data via unsecure email is prohibited.
  • Develop procedures for identifying, reporting and handling breaches of confidential data
  • Data custodian must be accountable for all data security for data collection as specified in the CMS Data Use Agreement
Data Retention
  • Retain all data files, including sample information and submitted data, for a minimum of 6 years
  • Develop confidentiality agreements for staff and subcontractors that include language related to HIPAA regulations, and obtain signatures from all personnel with access to survey information (including staff and all subcontractors) or involved in survey administration and data collection
    • Confidentiality agreements must be reviewed and re-signed periodically, at the discretion of the survey vendor, but not to exceed more than a three-year period
  • Monitor staff and subcontractors to ensure compliance with HIPAA regulations in regards to PHI and PII
  • Ensure Data Use Agreement (DUA) with CMS is kept up-to-date and that all DUA requirements are followed, including cell size suppression rules
  • Store survey-related paper or electronic data files securely and confidentially in accordance with requirements specified in the Quality Assurance Guidelines
Customer Support
  • Provide toll-free customer support telephone lines with live operator during regular business hours (to be established from the date of the pre-notification letter through the end of data collection)

    • Offer customer support in all languages the survey vendor uses to administer the survey
    • Respond to calls within 24-48 hours
Adherence to Quality Assurance Guidelines and Participation in Quality Assurance Activities
Demonstrated Quality Control Procedures
  • Demonstrated ability to conduct well-documented quality control procedures (as applicable) for:
    • In-house training of staff involved in survey operations
      • Printing, mailing, and recording of receipt of mail surveys
    • CATI administration of survey
      • Coding and editing of survey data and survey-related materials
    • Scanning or keying in survey data
    • Preparing final record-level data files for submission
    • All other functions and processes that impact survey administration
  • Participate in conference calls and site visits as scheduled by the Project Team as part of mandatory quality oversight activities
  • Develop and submit annual Quality Assurance Plans by specified due date
Documentation Requirements
Maintain Records

Must provide documentation as requested for site visits and conference calls, including but not limited to:

  • HIPAA compliance
  • Mail material production
  • Staff training records
  • Telephone interviewer monitoring records
  • File construction documentation

Must have capability to:

  • Keep electronic or hard copy files of staff training and dates
  • Maintain electronic or hard copy records of interviewer monitoring activities
  • Maintain electronic or hard copy records of survey mailing dates and dates of returned surveys
  • Maintain documentation related to mail production activities, including quality checklists and seeded mail logs
  • Maintain other documentation necessary to allow the Project Team to review survey protocol implementation during site visits
  • Maintain documentation of actions required (and implemented) as a result of site visit findings by the Project Team
Survey Training
Survey Training
  • Attend and successfully complete all training sessions
    • The following personnel from vendor and subcontractor organizations must attend (at a minimum):
      • Project Manager
      • Mail Center Supervisor
      • Call Center Supervisor
      • Project staff member(s) responsible for the following functions:
        • Decrypting the sample file and performing sample file quality checks
        • Programming the CATI script
        • Preparing and submitting the survey data file
  • Pass a post-training quiz measuring comprehension of survey protocols
  • Participate in additional survey training sessions
Vendor Approval Term
  • Survey vendors are approved for 1 year. Approval as a survey vendor in prior years doesn’t guarantee future approval.
Administer the Survey According to All Survey Specifications
  • Must review and follow all procedures described in the CAHPS Survey for MIPS and Next Generation Model Quality Assurance Guidelines Version 2021
  • Must agree to all conditions in the Vendor Participation Application

± Survey vendors approved for 2021 survey administration may conduct this component of the 2021 Facilities and Systems and Mixed-Mode business requirements remotely on an as-needed basis during the COVID-19 Public Health Emergency. Vendors must continue to adhere to the vendor approval criteria codified in §414.1400 throughout 2021 administration of the survey.

Download a print-friendly PDF version of the 2021 CAHPS for ACOs Survey Minimum Survey Vendor Business Requirements.